Operations Updates - Addiction and Recovery Treatment Services (ARTS) Enhancing Authorization Reviews
As part of our ongoing commitment to clinical excellence and member-centered care, Sentara Health Plans Behavioral Health Utilization Management (SHP BH UM) is refining our review process for ARTS authorization requests. These enhancements are designed to support more precise alignment of services with member needs, while continuing the high standards of review we have always upheld.Commercial Behavioral Health Authorization Fax Numbers and Forms
Commercial Behavioral Health authorization fax numbers and forms for urgent and non-urgent requests.Government Behavioral Health Authorization Fax Numbers and Forms
Government Behavioral Health authorization fax numbers and forms for urgent and non-urgent requests.CMS Guidelines for Anatomical Modifiers
Sentara Health Plans will apply a claims edit to deny radiology procedure codes requiring anatomical modifiers when the modifier is not submitted on the claim. Without the proper anatomical modifier applied to the procedure code, there is a risk of duplicate claims payment, incorrect procedure-to-procedure bundling, incorrect frequency limitations, and unnecessary medical record review.Medicare Severity Diagnosis Related Groups (MS DRG) 870 Claims for Septicemia or Severe Sepsis
MS DRG 870 reports claims for septicemia or severe sepsis with mechanical ventilation greater than ninety-six hours. The edit will deny claims for MS DRG claims when the discharge status is not equal to (02,05,30,82,85) and reports with inpatient procedure code 5A0955A and the length of stay less than 96 hours.Sexually Transmitted Infections
Sentara Health Plans will deny claim lines when two or more of the service codes listed below are billed by the same provider on the same date of service including when modifier 59 is applied.Anatomical Modifiers - Fingers and Toes
Effective August 1, 2025, Sentara Health Plans will be deploying an edit that reviews surgical procedures on the foot and toes (code range 28001-28899*) and the hand and fingers (code range 26010-26989*) when they are not reported with the appropriate anatomical modifier.Institutional Billing for No Cost Items
Effective August 1, 2025, Institutional providers should not have to report on the usage of a no cost item. However, claims providers may be required to bill a no cost item due to claims processing edits that require an item (even if received at no cost) to be billed along with an associated service.Provider Agreement Documentation Address - Operations Update
Any notice, request, instruction or other document or correspondence required to be given under the Provider Agreement, if sent by registered mail, overnight delivery or certified mail, or return receipt requested, must be mailed to the following address: Vice President, Network Management Sentara Health Administration, Inc. 1300 Sentara Park Virginia Beach, Virginia 23464.Zelis Payment Network - Provider Payment Processing
Provider payment processing is transitioning to the Zelis Payments Network.OncoHealth to Administer the Oncology Benefits Program - Operations Update
OncoHealth will administer Sentara Health Plans' Oncology Benefits Management Program.Genetic Testing Management Partnership Implementation - Operations Update
The Genetic Testing Management (GTM) program includes new and revised medical policies, a new authorization request process, guidelines, and consistent preservice reviews for certain genetic testing services that will be applicable to both ordering and rendering provider partners.Change In Enrollment Policy for Certain Dual Eligible Medicare-Medicaid Enrollees
Change In Enrollment Policy for Certain Dual Eligible Medicare-Medicaid Enrollees